Ten tips on polymyalgia rheumatica and temporal arteritis
Musculoskeletal GPSI Dr Louise Warburton’s tips on spotting and managing these associated pathologies
Musculoskeletal GPSI Dr Louise Warburton's tips on spotting and managing these associated pathologies
1 Patients presenting with polymyalgia rheumatica (PMR) will typically be over 50. If they are younger and have symptoms suggestive of PMR, then they should be referred for a specialist opinion before starting therapy.
2 PMR is one of the most common indications for long-term steroid therapy in the community and one of the most commonest inflammatory rheumatic diseases of the elderly. Diagnostic features are bilateral shoulder and/or pelvic girdle pain or aching morning stiffness lasting more than 45 minutes, and raised ESR and/or CRP – in other words, evidence of an acute phase response. If inflammatory markers are normal and the diagnosis still seems likely, referral for specialist opinion is best.
3 Remember that the diagnostic features of PMR can mimic many other diseases. The proximal pain and stiffness syndrome – the main symptoms of PMR – can occur in many other illnesses. A third of the patients have systemic symptoms such as fever, anorexia and weight loss. Many may have distal musculoskeletal manifestations such as peripheral arthritis, distal swelling with pitting oedema and carpal tunnel syndrome.
PMR is also associated with giant cell arteritis (GCA) in 10% of cases and up to 50% of cases with GCA may have polymyalgia at presentation. Raised ESR/CRP can occur in other inflammatory conditions such as rheumatoid arthritis.
4 Exclude other significant diseases. These include cancer, infection, rheumatoid arthritis, thyroid problems, local shoulder and neck arthritis and statin-related myalgia/myopathy. Investigate with full blood count, full biochemical screen, ESR and CRP, serum electrophoresis to exclude myeloma, rheumatoid factor, urinalysis to exclude diabetes and glomerulonephritis and a chest X-ray to exclude malignancy.
5 Once the diagnosis has been made, start low-dose steroids. A suggested dosing regimen is:
• 15mg daily for three weeks
• 12.5mg daily for three weeks
• 10mg daily for four to six weeks
• reduce by 1mg every four to eight weeks.
6 Make sure you evaluate the response to steroid treatment. If there is a 70% improvement in patient symptoms within a week, then it is likely to be PMR. If the response is less dramatic, consider referral to specialist care. Treatment monitoring should include:
• morning stiffness
• other risk factors of steroid use such as osteoporosis and diabetes
• blood monitoring – FBC, U&E, glucose and ESR/CRP.
Treatment is likely to need to continue for 18 months to two years.
7 Don't forget to introduce bone protection. High-risk patients, such as those aged over 65, should commence bisphosphonates (see guidance on the Royal College of Physicians website on use for steroids and bone protection www.rcp.org.uk).
8 As both temporal arteritis and PMR often occur together, there are suggestions that the underlying pathophysiology is the same. Temporal arteritis should be suspected if patients over the age of 50 present with:
• sudden headache or pain in the head – it can
be unilateral and felt over the temporal area
• scalp tenderness (pain on combing hair)
• jaw and tongue claudication
• visual symptoms such as blurring, diplopia and amaurosis fugax (sudden visual loss)
• fever, weight loss , sweats, tiredness, depression
• polymyalgia – in fact TA can develop as a complication of existing PMR
• sometimes limb claudication.
9 In temporal arteritis, there may be an abnormal temporal artery. It may be thickened, tender or have absent or reduced pulsation.
Other signs on examination include:
• scalp tenderness
• visual field defect; abnormal pupillary response
• swollen optic disc on fundoscopy; optic neuritis
• upper cranial nerve palsies.
10 If there is visual disturbance, TA is an absolute medical emergency and steroids should be started without delay or there is a risk of sight loss. Hospital referral as an emergency should be made; a temporal artery biopsy will then be performed if possible and IV steroids started. If there are no visual disturbances, check ESR/CRP and blood screen as for PMR and institute steroid treatment in a dose of 40-60mg per day (0.75mg/kg). Steroid regime is 40-60mg prednisolone daily for four weeks or until ESR/CRP are normal and symptoms resolve. Taper steroids by 10mg every two weeks until 20mg is reached. Reduce by 2.5mg every two to four weeks until 10mg and then by 1mg every one to two months. Monitor as for PMR and be prepared for relapses – defined as a rise in ESR of more than 40mm and a fever more than 38°C for more than a week with no other obvious cause, plus worsening headache, scalp tenderness or suggestive symptoms. Refer for specialist advice if an increase in steroid dose does not relieve the symptoms.
Dr Louise Warburton is a GPSI in musculoskeletal medicine in Ironbridge, Shropshire
Competing interests None declaredTemporal arteritis Related Seminar: Musculoskeletal Medicine
Clinical Seminar: Musculoskeletal Medicine
What: A one day refresher to update GPs on the hot issues and trickiest dilemmas in rheumatology and orthopaedics.
When: Thursday 5 November 2009
Where: Raddison Hotel, Manchester
Next steps: Find out more and book